Rebecca Hanlon

Extracapsular spread in oral squamous cell carcinoma.

Extracapsular spread (ECS) in the cervical lymph nodes represents the most significant adverse prognostic indicator in oral squamous cell carcinoma (OSCC).

SERPINE1 and SMA expression at the invasive front predict extracapsular spread and survival in oral squamous cell carcinoma.

Background:Extracapsular spread (ECS) in cervical lymph nodes is the single-most prognostic clinical variable in oral squamous cell carcinoma (OSCC), but diagnosis is possible only after histopathological examination. A promising biomarker in the primary tumour, alpha smooth muscle actin (SMA) has been shown to be highly prognostic, however, validated biomarkers to predict ECS prior to primary treatment are not yet available.Methods:In 102 OSCC cases, conventional imaging was compared with pTNM staging. SERPINE1, identified from expression microarray of primary tumours as a potential biomarker for ECS, was validated through mRNA expression, and by immunohistochemistry (IHC) on a tissue microarray from the same cohort. Similarly, expression of SMA was also compared with its association with ECS and survival. Expression was analysed separately in the tumour centre and advancing front; and prognostic capability determined using Kaplan–Meier survival analysis.Results:Immunohistochemistry indicated that both SERPINE1 and SMA expression at the tumour-advancing front were significantly associated with ECS (P<0.001). ECS was associated with expression of either or both proteins in all cases. SMA+/SERPINE1+ expression in combination was highly significantly associated with poor survival (P<0.001). MRI showed poor sensitivity for detection of nodal metastasis (56%) and ECS (7%). Both separately, and in combination, SERPINE1 and SMA were superior to MRI for the detection of ECS (sensitivity: SERPINE1: 95%; SMA: 82%; combination: 81%).Conclusion:A combination of SMA and SERPINE1 IHC offer potential as prognostic biomarkers in OSCC. Our findings suggest that biomarkers at the invasive front are likely to be necessary in prediction of ECS or in therapeutic stratification.

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach.

The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM).Background The contemporary treatment of oropharyngeal squamous cell carcinoma (SCC) is an area of debate. We report outcomes of a minimally invasive approach involving transoral laser microsurgery (TLM). Methods A consecutive series of patients (n = 153) undergoing primary TLM for oropharyngeal SCC from 2006 to 2013 was studied. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry and high-risk HPV DNA in situ hybridization. Survival analyses were evaluated using Kaplan–Meier statistics. Results Tumor subsites included tonsil (n = 94; 61.5%), tongue base (n = 38; 24.8%), and soft palate (n = 21; 13.7%), with the majority being American Joint Committee on Cancer (AJCC) stage III/IVa (n = 124; 81.0%) and HPV-positive (n = 101; 66.0%). Three-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 84.5%, 91.7%, and 78.2%, respectively. HPV-positivity portended favorable oncologic outcomes. One-year gastrostomy tube (G-tube) dependency was 1.3%. Conclusion To the best of our knowledge, this is the largest single-center TLM oropharyngeal SCC series to date. Our data suggest that TLM +/− postoperative radiotherapy (PORT) results in at least as good oncologic outcomes as chemoradiotherapy (CRT), while conferring swallowing function advantages.

Skull base osteomyelitis after maxillectomy: a rare complication

We report a case of skull base osteomyelitis that presented 4-8 weeks after a level 2 maxillectomy for a plexiform ameloblastoma of the right posterior maxilla. This is an extremely rare complication, and we know of no previously reported cases that developed after maxillectomy. We summarise the presentation, differential diagnosis and management.

Tailored approach to oromandibular reconstruction in patients with compromised lower limb vessels: Tailored approach to oromandibular reconstruction

The purpose of this study was to compare outcomes for segmental reconstruction of the mandible between patients who underwent reconstruction with a fibula flap (group 1), and those with an alternative osseous free flap in which the fibula flap was unsuitable either for defect reasons (group 2) or in which the fibula flap could not safely be harvested because of compromised leg vessels (group 3).

The added value of 18F-fluorodeoxyglucose positron emission tomography computed tomography in patients with neck lymph node metastases from an unknown primary malignancy.

BACKGROUND The search for a primary malignancy in patients with a metastatic cervical lymph node is challenging yet ultimately of utmost clinical importance. This study evaluated the efficacy of positron emission tomography computed tomography in detecting the occult primary, within the context of a tertiary referral centre head and neck cancer multidisciplinary team tumour board meeting. METHODS Thirty-two patients (23 men and 9 women; mean and median age, 61 years) with a metastatic cervical lymph node of unknown primary origin, after clinical examination and magnetic resonance imaging, underwent positron emission tomography computed tomography. RESULTS The primary tumour detection rate was 50 per cent (16/32). Positron emission tomography computed tomography had a sensitivity of 94 per cent (16/17) and a specificity of 67 per cent (10/15). Combining these results with those of 10 earlier studies of similar patients gave an overall detection rate of 37 per cent. CONCLUSION Positron emission tomography computed tomography has become an important imaging modality. To date, it has the highest primary tumour detection rate, for head and neck cancer patients presenting with cervical lymph node metastases from an unknown primary.

1 UICC/AJCC pTNM staging in oral squamous cell carcinoma: ECS should now be grouped as pN3

Background: The role of TNM staging is to aid the clinician in planning treatment and to indicate prognosis. It serves to evaluate and compare results of treatments as well as stratification of patients into clinical trials. Existing treatments for OSCC favour surgery with widespread use of neck dissections. Currently pTNM takes no account of extracapsular spread (ECS). Methods: From a consecutive cohort of 489 OSCC patients treated by primary surgery, pN was recorded and the presence, pattern and severity (micro/macro) of ECS was noted in those 400 receiving neck dissections. Results: Using the current staging, 221 (55%) were pN0, 72 (18%) pN1, 105 (26%) pN2 but only 2 (0.005%) were pN3. 101 (25%) of the patients had ECS. Extracapsular spread (ECS) in the cervical lymph nodes was the single most significant adverse prognostic indicator of all those recorded. ECS doubled the incidence of local recurrence and distant metastases, but tripled regional failure. Patients with macroscopic ECS had a 5-year OS of 19% compared with 31% in microscopic ECS. The single change of reclassifying ECS to pN3 resolved the obvious imbalance in nodal stage cased by “underuse” of pN3 in the existing system. With this change 48 (12%) were pN1, 30 (8%) were pN2 and 101 (25%) were pN3 and these stagings were reflected by progressive and uniform worsening of OS and DSS. This reclassification is currently under consideration by AJCC/UICC. Conclusions: Reporting of ECS is essential in accurate prognostication and we advocate that all patients with OSCC and ECS should be grouped as pN3.